The holidays are here, and most people are hurrying around buying presents, preparing traditional holiday dishes, decorating the house, and the scent of fresh pine lingers in the air. It is, according to the famous Christmas song, "The most wonderful time of the year." It is a very busy time of the year for everyone.
It is also a busy time for our patients. Most of you have probably seen an increase in the number of elective surgeries, especially total joint replacements, being performed in the fall. The most likely reason is that people want to get their surgeries done before the end of the year before the very high deductible costs begin again in January. I'm sure all your units were bursting at the seams trying to accommodate all these patients.
Last year, the Centers for Medicare & Medicaid Services (CMS) rolled out its bundled payment model for total joint replacements, the Comprehensive Care Joint Replacement (CJR). The goal of this program is to standardize care and cut costs. It is designed to increase coordination and collaboration among all healthcare professionals involved in a patient's care.
The problem is that this rollout happened before all these collaborations were in place. The CMS moved back the date of implementation from January 1, 2016, to April 1, 2016, so some of these agreements could be finalized. Hospitals in one of the 67 metropolitan service areas (MSAs) covered by this model have been allowed to enter into financial agreements with skilled nursing facilities (SNFs) and physicians. For those of you who happen to live in one of these MSAs, you know the challenges that you and your patients face. Shortened hospital stays and fragmented transitional care to SNFs or rehabilitation centers have been concerns among orthopaedic nurses.
The National Association of Orthopaedic Nurses (NAON) was asked to provide feedback to the CMS last year during the public reporting period, and members of the NAON Executive Board drafted a response that was sent to the CMS. The major concerns were not addressed. The rollout was expedited as orthopaedic nurses continued to support patients with hip and knee replacement transition through the continuum of care, from hospital to post-acute care in home health settings or extended care facilities. Health systems were tasked with maintaining quality outcomes and preventing readmissions, while balancing the financial uncertainty of absorbing the costs of an entire 90-day episode of care.
According to Daly (2016), even with a later implementation date, approximately 60% of hospitals that are mandated to participate in the CJR anticipate that they will receive penalties in 2017. Because of the heightened emphasis on post-acute care, many hospitals are examining the use of nurse navigators to follow CJR patients throughout the episode, especially relating to post-acute care, where many patients may fall off a hospital's radar. In a recent survey of hospitals with CJR bundles, 75% of respondents to the provider survey said they were hiring navigators or coordinators to manage CJR patients.
That is the good news for orthopaedic nurses. Our clinical and organizational skills are finally being recognized and utilized by hospital systems. This role offers orthopaedic nurses the opportunity to truly interface and collaborate with our healthcare peers and patients.
There has been lively discussion about the nurse navigator role on NAON's forum, and I would suggest that all members look at the comments and suggestions that are there. NAON is working toward facilitating group discussion on a monthly basis for those nurses who are either beginning the orthopaedic nurse navigator role or urging your hospital administrations to fund that role. The collaboration and excitement found on the forum are very gratifying. NAON nurses work together to provide expert care.
Along with the good news comes the bad news. Late last summer, the CMS decided to include surgical hip and femur fracture treatment (SHFFT) patients into the CJR (CMS, 2016). NAON was again asked to respond to the newest CMS proposal during the public comment period. At issue is the CMS's belief that the SHFFT model beneficiaries are similar to CJR model beneficiaries who undergo hip replacement for fracture. The CMS believes that the same episode duration as the CJR model of 90 days is appropriate for SHFFT model episodes to include the full time for recovery of function for these Medicare beneficiaries.
One of NAON's Executive Board members, Mickey Haryanto, summarized NAON's concerns, and these concerns were sent to the CMS on behalf of NAON. I would like to share these with you:
While a 90-day episode may be an appropriate episode time frame, there are major differences between the elective total joint population and the cohort of SHFFT patients related to:
* Hip fracture/femur fracture repair is an emergent/urgent procedure vs. an elective procedure for hip replacement. Patients experiencing hip or femur fracture are not similar to elective hip arthroplasty patients in that there is no time for prehospital education via a joint replacement class, a prehab session with PT/OT (Joint Camp) or prehospital optimization of underlying medical conditions.
* While a systematic review of the literature reported that while prehab may not decrease hospital length of stay, or significantly increase benefits in function, quality of life, and pain, it does positively impact by decreasing the likelihood that the patient will be discharged to a rehabilitation hospital (Cabilan, Hines, & Munday, 2016).
* There is lack of preoperative optimization for underlying medical conditions, other than determination that the patient is safe for surgery as early as possible.
* The urgent nature precludes prehospital education and family/coach preparation for recovery. The prehospital preparation is a leading practice resulting in positive outcomes for hip replacement patients.
* Readmission rates and overall acuity related to comorbidities and frailty are likely to be higher than hip replacements. Readmission rates will negatively impact reimbursement rates.
* For elective hip arthroplasty, discharge to home is more often appropriate than with the SHFFT population. The age, underlying medical comorbidities, and lack of preparation afforded by the urgency of the procedure impact the post-hospital recovery. This should be taken into account.
* Utilization of post-hospital SNF rehabilitation is higher with hip and femur fracture. The variation in care will need to be addressed in regions where patients choose SNF care based on geography or other factors, rather than quality outcomes. (personal communication, August 26, 2016)
Another concern that Mickey expressed is a missed opportunity for patients with fragility hip fracture related to bone health and the use of fracture liaison services. Instead of rolling SHFFT into the CJR, this unique group of patients may be best served by developing a bundle paralleling best practices for patients with fragility fracture. The document is also unclear as to the expectations for follow-up care during the 90-day episode. There is no outline for fracture prevention, pharmacological intervention, lifestyle modifications, or bone health intervention. That is a major shortcoming as we want to prevent another fragility fracture.
For nurses, this bundle represents an opportunity for research and implementation of best practices. Nurses caring for orthopaedic patients in settings outside of acute care hospitals will need to be educated on the impact that their nursing care will have on the bundle. This is an opportunity for NAON to expand its reach to these nurses (M. Haryanto, personal communication, August 26, 2016).
It is important for our members to know how hard the NAON Executive Board is working to facilitate discussion and impact legislation that affects members and our patients. Our patients are at the center of all that we do, and this newest addition to the CJR bundle will surely push competency and best practices in care to the forefront in order to maximize reimbursement and patient outcomes.
I wish all of you the happiest of holiday seasons. Together, in the New Year, we will continue to work to promote the art and science of orthopaedic nursing and to deliver the highest quality care to our patients.
References